Contraceptive Pill Review Form

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

Last Updated: 29/11/2019

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Contraceptive Pill Review

    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
    Will you be 35 years or older within the next 12 months?
    Smoking Status
    Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months? (optional)
    Have you been diagnosed with or experienced any of the following conditions in the past 12 months? (optional)
    Are you currently taking any of the following medications? (optional)
    Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *
    Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *
    Have you forgotten to take your pill on more than one occasion per month?
    Would you like to discuss 'what to do in the event of a missed pill' with you GP or practice nurse?
    Would you like to discuss long acting reversible contraception options with you GP or practice nurse?
    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
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